Healthcare Provider Details

I. General information

NPI: 1871553453
Provider Name (Legal Business Name): CLINIC PHARMACY OF MANGHAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 HIGHWAY 132
MANGHAM LA
71259-5268
US

IV. Provider business mailing address

252 HIGHWAY 132
MANGHAM LA
71259-5268
US

V. Phone/Fax

Practice location:
  • Phone: 318-248-3338
  • Fax: 318-248-3399
Mailing address:
  • Phone: 318-248-3338
  • Fax: 318-248-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY.006681-IR
License Number StateLA

VIII. Authorized Official

Name: KAYLA BRIDGES
Title or Position: OWNER/AO
Credential: PD
Phone: 318-248-3338